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Module Instructions The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary, an illustrated interactive guide to clinical dermatology and dermatopathology.dermatology glossary We encourage the learner to read all the hyperlinked information. 2

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Goals and Objectives The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with erythroderma. By completing this module, the learner will be able to: Identify and describe the morphology of erythroderma Name common diseases and medications associated with erythroderma Explain the potential morbidity and mortality in erythrodermic patients Discuss the initial management of an erythrodermic patient 3

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Erythroderma: The Basics Also called exfoliative dermatitis Defined as generalized redness or scaling of the skin, affecting a significant portion (over 90%) of the body surface area (BSA) Vesicles and pustules are usually absent May present with extensive telogen effluviumtelogen effluvium Erythroderma is not a specific diagnosis, but the clinical manifestation of a variety of underlying diseases 4

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Case One: History HPI: Mr. Ashton is a 63-year-old man who presents to the dermatology clinic with a rapid progression of skin redness, which is covering most of his body PMH: coronary artery disease s/p 3v CABG, hypertension, psoriasis Medications: beta-blocker, aspirin, ace-inhibitor, statin, and topical clobetasol. No new medications. Allergies: none Family history: no history of skin disorders Social history: lives by himself in an apartment Health-related behaviors: no tobacco, alcohol or drug use ROS: pruritus, fatigue 8

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Evaluation of Erythroderma In general, evaluation of erythroderma begins with a thorough history, including a complete medication history Physical exam requires special attention to the vital signs, nails, mucosa, lymph nodes and evaluation for hepatosplenomegaly Baseline blood work, skin biopsy and, at times, cytologic or histologic evaluation of lymph nodes is the next step in evaluation Multiple (and repeat) skin biopsies may be necessary to make a definitive diagnosis 10

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Evaluation of Erythroderma Underlying malignancy may need to be excluded Regardless of the underlying cause, if a patient appears unstable or toxic, admission to the hospital is recommended The evaluation of a patient with erythroderma should include a dermatology consult 11

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Back to Case One Mr. Ashton is a 63-year-old man with a history of psoriasis who presented with generalized erythema. Given his concerning vital signs, Mr. Ashton was admitted to the hospital for evaluation and treatment. 12

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Case One, Question 1 Answer: d What is the most likely diagnosis in this case? a.Atopic dermatitis flare (no history of atopic dermatitis. AD erythroderma tends to present more with weeping and crusting) b.Cutaneous T-cell lymphoma (hard to tell the difference, but CTCL erythroderma may present with symmetric islands of uninvolved skin. Also may spare areas of skin that are frequently folded, such as the abdomen) c.Idiopathic d.Psoriatic erythroderma (patient has known psoriasis) e.S. aureus scalded skin syndrome (usually presents with cutaneous tenderness and widespread superficial blistering and denudation) 14

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Psoriatic Erythroderma Erythrodermic psoriasis is a severe form of psoriasis that can arise acutely or follow a more chronic course Can arise in patients with long-standing psoriasis or can occur de novo as the initial presentation of psoriasis There are a number of triggers for erythrodermic psoriasis, including: Discontinuation of potent topical or oral treatment, medications used for other conditions, infection (including HIV), pregnancy and emotional stress 16

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Case Two Mrs. Grace Barringer 17

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Case Two: History HPI: Mrs. Barringer is a 54-year-old woman with progressive redness, starting on the scalp and progressing towards the trunk and extremities over the last three weeks PMH: asthma, chronic dry, itchy skin, and hay fever Medications: daily multivitamin, albuterol inhaler as needed, moisturizers, occasional antihistamines Allergies: none Family history: noncontributory Social history: lives with her husband, has three grown children Health-related behaviors: no tobacco, alcohol or drug use ROS: itches, emotional distress over skin changes 18

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Case Two, Question 1 Answer: a What is the most likely diagnosis? a.Atopic dermatitis (History of asthma, hay fever and chronic, dry itchy skin suggestive of atopic dermatitis) b.Cutaneous T-cell lymphoma (Hard to tell the difference, but CTCL erythroderma may present with symmetric islands of uninvolved skin. Also may spare areas of skin that are frequently folded, such as the abdomen) c.Idiopathic (Possible, but atopic dermatitis more likely given history of atopic disease) d.Pityriasis rubra pilaris (Typically presents with a reddish orange, scaling dermatitis with islands of normal skin) e.Psoriatic erythroderma (No history of psoriasis) 21

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Case Two, Question 2 Which of the following treatments should take priority in any patient with erythroderma? a.Leg elevation b.Oral antibiotics c.Remove any potential offending and unnecessary medications d.Topical corticosteroids 22

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Case Two, Question 2 Answer: c Which of the following treatments should take priority in any patient with erythroderma? a.Leg elevation b.Oral antibiotics c.Remove any potential offending and unnecessary medications d.Topical corticosteroids 23

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Initial Management of Erythroderma Regardless of the underlying cause, the initial management of erythroderma remains the same Remove any potential offending and unnecessary medications Address nutrition, fluid and electrolyte balance Provide local skin care with soaks or wet dressings to weeping or crusted sites, bland emollients and mid-potency topical corticosteroids 24

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Erythroderma: Prognosis Prognosis depends on the underlying cause Determining the underlying etiology and removing any contributing external factors (especially medications) remain the most important factors in treatment 26

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Take Home Points Erythroderma is a clinical manifestation of a variety of underlying diseases Defined as generalized redness or scaling of the skin, affecting a significant amount of the BSA Potential risk for morbidity and mortality and hospitalization is often required Initial management of erythroderma includes removing any potential offending and unnecessary medications 27